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A Large Cohort Analysis of Epiglottic Phenotypes and Pharyngeal Residue

Kravietz, Adam; Crosby, Tyler; Yang, Jackie; Balou, Stamatela; Dion, Gregory R.; Logan, Ashley; Amin, Milan R.
Objective: To describe the phenotypic characteristics of the epiglottis at rest and their impact on vallecular residue. Methods: Videofluoroscopic studies (VFSS) were pooled from 2 Laryngology practices, and Image J was used to measure epiglottic anatomic features at rest. Studies were rated by the MBSImp and presence of vallecular residue following swallow of thin and puree boluses. A conditional inference tree analysis was performed to isolate which epiglottic parameters were risk factors for presence of vallecular reside followed by logistic regression. Results: The majority of patients had a normal shaped epiglottis, followed by omega shape. The mean angle of the epiglottis from the hyoid was approximately 90°. Only abnormal epiglottic movement was associated with increased risk of residue for thin boluses (OR 35.09, CI 10.93-158.66, P <.001). However, in those with normal epiglottic movement, age >70 years old was associated with increased risk of residue (OR 3.98, CI 1.73-9.23, P =.001). For puree boluses, a normal or omega shaped epiglottis was associated with residue (OR 5.19, CI 2.41-11.51, P <.001), and this relationship was further modulated by increased distance of the epiglottic tip from the posterior pharyngeal wall. No other anatomic features of the resting epiglottis were associated with residue. Comorbidities potentially affecting swallow were infrequent in the cohort and were not associated with residue. Conclusion: Abnormal epiglottic movement is associated with aspiration, and in this study we find that abnormal epiglottic movement increases the risk of vallecular residue and that older age is a risk factor for residue. The resting properties of the epiglottis do not appear to be associated with abnormal epiglottic movement or residue.
SCOPUS:85181689250
ISSN: 0003-4894
CID: 5630122

Radiographic Magnification on Videofluoroscopy: An Important Variable to Consider for Scaled Analyses of Swallowing

Molfenter, Sonja M; Jones-Rastelli, Rebecca Brynn; Balou, Matina
PURPOSE/OBJECTIVE:Traditionally, kinematic measures on videofluoroscopy require the use of an external scalar (such as a penny) to transform pixels to absolute distances. Videofluoroscopy is subject to image magnification based on the distance of the feature of interest to the X-ray source. However, the impact of the position/location of the external scalar on swallowing measures is unknown. Our goal was to systematically investigate the accuracy of various common external scalar locations in lateral and anterior-posterior (A-P) view. METHOD/METHODS:U.S. pennies were taped to a styrofoam head in three positions (on the left and right lateral neck and in midline submentally). Locations were measured to ensure equal left and right, as well as midline, placement. A metal screwdriver (6 mm in diameter) was inserted into the premanufactured hole that is centrally located at the bottom of the styrofoam head. The head was centered on a medical tray and placed in the middle of a Siemens Alpha C-arm Fluoroscope field. ImageJ was used to measure penny length in pixels (three locations) in both lateral and A-P views. Penny length was known (19.05 mm), and, therefore, used to derive screwdriver size (for each location) for comparison to the actual screwdriver size. RESULTS:All scalars overestimated the screwdriver size ranging from 6.55 to 7.87 mm, representing a 9%-31% inflation. Scalars closer to the X-ray source had the largest magnification. CONCLUSIONS:Our results confirm that image magnification of external scalars is a significant source of variability that is currently unaccounted for in the swallowing literature. Recommendations for future research design/measurement methods are provided.
PMID: 37889234
ISSN: 1558-9102
CID: 5607422

A scoping review of the methods used to capture dysphagia after anterior cervical discectomy and fusion: the need for a paradigm shift

Molfenter, Sonja M; Amin, Milan R; Balou, Matina; Herzberg, Erica G; Frempong-Boadu, Anthony
OBJECTIVE:Dysphagia is the most commonly reported complication of annterior cervical discectomy and fusion (ACDF) surgery. However, the incidence of dysphagia post-ACDF varies widely-partly attributable to differing outcome measures used to capture dysphagia. Our objective was to conduct a scoping review of the literature to quantify which dysphagia outcome measures have been employed post-ACDF and examine trends by study design, year, and location. METHODS:After removing duplicates, 2396 abstracts were screened for inclusion. A total of 480 studies were eligible for full-text review. After applying exclusion criteria, data was extracted from 280 studies. We extracted the dysphagia outcome measure(s), study design (prospective vs retrospective), year, and location (country). Approximately 10% of studies were repeated for intra-rater agreement. RESULTS:In total, 317 dysphagia outcome measures were reported in 280 studies (primarily retrospective-63%). The largest proportion of outcome measures were categorized as "unvalidated patient-reported outcome measures" (46%), largely driven by use of the popular Bazaz scale. The next most common categories were "insufficient detail" and "validated patient-reported outcome measures" (both 16%) followed by "chart review/database" (13%) and instrumental assessment (7%). Studies examining dysphagia post-ACDF steadily increased over the years and the use of validated measures increased in the past 10 years. CONCLUSIONS:This scoping review of the literature highlights that nearly half of the ACDF dysphagia literature relies on unvalidated patient-reported outcome measures. The current understanding of the mechanism, timeline, and presentation of dysphagia post-ACDF are likely limited due to the metrics that are most commonly reported in the literature.
PMID: 36625955
ISSN: 1432-0932
CID: 5410402

Alterations in Swallowing Six Weeks After Primary Anterior Cervical Discectomy and Fusion (ACDF)

Jones-Rastelli, R. Brynn; Amin, Milan R.; Balou, Matina; Herzberg, Erica G.; Molfenter, Sonja
This aim of this study is to characterize the nature and pathophysiology of dysphagia after ACDF surgery by precisely and comprehensively capturing within-subject changes on videofluoroscopy between preoperative and postoperative time points. 21 adults undergoing planned primary ACDF procedures were prospectively recruited and enrolled. Participants underwent standardized preoperative and six-week postoperative videofluoroscopic swallow studies. Videos were blindly rated using the Penetration-Aspiration Scale (PAS) and analysis of total pharyngeal residue (%C2-42), swallowing timing, kinematics, and anatomic change was completed. Linear mixed-effects modeling was used to explore the relationships between possible predictor variables and functional outcomes of interest that changed across timepoints. There was no change in PAS scores across timepoints. Total pharyngeal residue (%C2-C42) was increased postoperatively (p < 0.001). Our statistical model revealed significant main effects for timepoint (p = 0.002), maximum pharyngeal constriction area (MPCAN) (p < 0.001), and maximum thickness of posterior pharyngeal (PPWTMAX) (p = 0.004) on the expression of total pharyngeal residue. There were significant two-way interactions for timepoint and MPCAN (p = 0.028), timepoint and PPWTMAX (p = 0.005), and MPCAN and PPWTMAX (p = 0.010). Unsurprisingly, we found a significant three-way interaction between these three predictors (p = 0.027). Our findings suggest that in planned ACDF procedures without known complications, swallowing efficiency is more likely to be impaired than airway protection six weeks after surgery. The manifestation of impaired swallowing efficiency at this timepoint appears to be driven by a complex relationship between reduced pharyngeal constriction and increased prevertebral edema.
SCOPUS:85180873590
ISSN: 0179-051x
CID: 5631112

Swallow efficiency in patients with pulmonary disease due to nontuberculous mycobacteria [Meeting Abstract]

Balou, M; Kamelhar, D
Introduction: Non-tuberculous mycobacteria (NTM) is an intracellular microorganism that causes cavitary disease and nodular bronchiectatic disease of the lung. Patients with NTM appear to have impaired swallow function as represented by impaired airway protection and pharyngeal bolus clearance. It is unknown whether impaired swallowing contributes to the pathophysiology of NTM. Our aim is to determine swallow physiology in patients with bronchiectasis and NTM compared with a control group.
Method(s): Video fluoroscopy (VF) was prospectively collected from 195 patients: 132 patients with NTM (90 females; ages 30-90) and 63 agematched and sex-matched controlswith noNTM(39 females; ages 27-92). Two boluses of 3, 5, 10ml thin liquid, two 5ml puree Varibar, and cracker were analyzed per subject (N = 1755 swallows). Outcome measures included ordinal ratings of residue in the valleculae and pyriform sinuses.
Result(s): Inter-and intra-rater reliability of the ordinal ratings were assessed using one-way mixed intraclass correlation coefficients (ICC) (ICC(2,1)) on 20% of the data with good results (intra-rater: ICC = 0.92, 95% range CI 0.70-0.97 and inter-rater: ICC = 0.92, 95% range CI 0.81-0.97). The ratings of residue in the valleculae were significantly higher (worse) in the NTM group compared to the control group for one of the 3mL bolus (p = 0.008), for both 5 mL boluses (p = 0.009 and p = 0.004), both 10mL boluses (p = 0.0005 and p = 0.0006), puree (p = 0.006), cracker (p = 0.005). The ratings of residue in the pyriform sinuses were also significantly higher in the NTM group for 3 mL boluses (p = 0.0002 and p = 0.01), both 5 mL boluses (p = 0.0003 and p = 0.002), both 10mL boluses (p = 0.001 and p = 0.001), both puree trials (p<0.0001 and p<0.0001).
Conclusion(s): Future work is needed to elucidate responsiveness to swallowing treatment for patients with NTM
EMBASE:631571547
ISSN: 1432-0460
CID: 4413792

Swallow function and airway protection in patients with non-tuberculous mycobacteria [Meeting Abstract]

Balou, M; Salvo, C; Hon, S; Castillo, G; Casale, M; Wang, B; Kamelhar, D
Purpose: Non-tuberculous mycobacteria (NTM) can cause clinically significant lung disease and frequent pneumonias. It is unknown whether impaired swallowing contributes to the pathophysiology of NTM. Patients with NTM may exhibit decreased airway protection. Our aim is to determine airway protection and bolus clearance in patients with NTM. Method(s): Videofluoroscopy (VF) was prospectively collected from 98 patients with NTM (67 female; ages 33-88). Two boluses of 3,5,10 ml thin liquid, two 5 cc puree Varibar, cracker were analyzed per subject (N = 980 swallows).Outcome measures included Penetration/Aspiration Scale (PAS) and ordinal ratings of residue in the valleculae and pyriform sinuses. Worst PAS scores categorized subject as unsafe (C 3) or safe (B 2). The correlation between clinical information and the present of penetration/aspiration and pharyngeal residue structures was analyzed. Result(s): Inter-and intra-rater reliability of PAS ratings were assessed using two-way mixed intraclass correlation coefficients (ICC) on 20% of the data with excellent results (intra-rater: ICC 0.98, 95% CI 0.95-0.98 and inter-rater: ICC 0.85, 95% CI 0.69-0.92). The proportion of impaired swallows in the whole dataset was 12.9% (127/980 swallows with PAS scores C 3). There was no correlation between presence of penetration/aspiration and pharyngeal residue with productive cough, pneumonia, smoking history and presence of acid reflux. Conclusions (Including Clinical Relevance): Patients with NTM appear to have impaired swallow function as represented by impaired airway protection. Future work should explore swallowing physiology compared to a control group
EMBASE:628578275
ISSN: 1432-0460
CID: 4001222

An intensive swallowing exercise protocol for improving swallowing physiology in older adults with radiographically confirmed dysphagia

Balou, Matina; Herzberg, Erica G; Kamelhar, David; Molfenter, Sonja M
Purpose/UNASSIGNED:The aim of this study was to investigate improvements in swallowing function and physiology in a series of healthy older adults with radiographically confirmed dysphagia, following completion of an exercise-based swallowing intervention. Patients and methods/UNASSIGNED:Nine otherwise healthy older adults (six females, mean age =75.3, SD =5.3) had confirmed impairments in swallowing safety and/or efficiency on a modified barium swallow study. Each participant completed an 8-week swallowing treatment protocol including effortful swallows, Mendelsohn maneuvers, tongue-hold swallows, supraglottic swallows, Shaker exercises and effortful pitch glides. Treatment sessions were conducted once per week with additional daily home practice. Penetration-Aspiration Scale and the Modified Barium Swallowing Impairment Profile (MBSImP) were scored in a blind and randomized fashion to examine changes to swallowing function and physiology from baseline to post-treatment. Results/UNASSIGNED:There were significant improvements in swallowing physiology as represented by improved oral and pharyngeal composite scores of the MBSImP. Specific components to demonstrate statistical improvement included initiation of the pharyngeal swallow, laryngeal elevation and pharyngeal residue. There was a nonsignificant reduction in median PAS scores. Conclusion/UNASSIGNED:Swallowing physiology can be improved using this standardized high-intensity exercise protocol in healthy adults with evidence of dysphagia. Future research is needed to examine the individual potential of each exercise in isolation and to determine ideal dose and frequency. Studies on various etiological groups are warranted.
PMCID:6375531
PMID: 30804667
ISSN: 1178-1998
CID: 3698302

Outcomes of a standardized exercise protocol in healthy adults with incidental findings of swallowing impairment on video fluoroscopy [Meeting Abstract]

Balou, M; Herzberg, E G; Kamelhar, D; Molfenter, S M
Purpose: Despite being widely adopted in clinical practice, the rehabilitative potential of swallowing exercises is not well documented (Langmore & Pisegna, 2015). While collecting a sample of 98 videofluoroscopies (VF) from healthy individuals to serve as a control group for an unrelated study, we discovered 13 subjects with incidental findings of impaired swallowing (safety and/or efficiency deficits). Our purpose was to explore the impact of a standardized 'one-size-fits-all' treatment (tx) protocol on impaired swallowing function in this cohort of otherwise healthy individuals. Method(s): 13 healthy individuals (9 F, mean age = 71.5, SD = 11.9) completed 8 weeks of swallowing exercises. Treatment sessions (once per week) consisted of 20 repetitions of each of the following exercises: effortful swallows, tongue hold swallows, supraglottic swallows, Shaker exercises and Mendelsohn maneuvers, as well as 10 repetitions of effortful pitch glides. Subjects were also asked to complete daily homework consisting of 3 additional treatment sets per day. VF was collected pre-and post-tx with a standardized protocol and scored using the MBSimPTM method. Scores for components 1-5 and 6-16 were combined for an oral total (OT) and pharyngeal total (PT) respectively. Wilcoxon rank sum tests compared OT and PT scores from pre-to post-tx. Result(s): The pre-tx and post-tx OT median scores remained unchanged (4). The median PT score was 10 pre-tx (range 2-14) and reduced to 7 post-tx (range 3-11), though this change narrowly missed statistical significance (Z =-1.99; p = .058). Post-hoc evaluations revealed that 8 subjects demonstrated improved PT scores, 2 worsened, 3 were unchanged and that the greatest changes came from components 6 (initiation of the pharyngeal swallow), 8 (laryngeal elevation), 15 (tongue base retraction) and 16 (pharyngeal residue). Conclusions (Including Clinical Relevance): Our sample of otherwise healthy individuals with VF evidence of impaired swallowing completed a standardized 'one-size-fits-all' approach to dysphagia rehabilitation that is common place in clinical practice. The approach appeared to rehabilitate aspects of swallowing function-especially in the pharyngeal phase-for the majority of subjects. Future research should compare physiologically-targeted exercises with one-size-fits all approaches. Further investigations into dose, frequency and maintenance of exercise interventions will be vital contributions
EMBASE:631570687
ISSN: 1432-0460
CID: 4413802

Pharyngeal bolus clearance in patients with nontuberculous mycobacteria [Meeting Abstract]

Balou, M; Castillo, G; Wang, B; Kamelhar, D
Purpose: Non-tuberculous mycobacteria (NTM) is an intracellular microorganism that causes cavitary disease and nodular bronchiectatic disease of the lung. Common symptoms include chronic cough, sputum production and frequent pneumonias. Patients with NTM appear to have impaired swallow function as represented by impaired airway protection. Our aim is to determine bolus clearance in patients with NTM compared with a control. Method(s): Videofluoroscopy (VF) was prospectively collected from 195 patients:132 patients with NTM (90 females; ages 30-90) and 63 age-and sex-matched normal controls with normal pulmonary function tests and no pulmonary disease (39 females; ages 27-92).Two boluses of 3, 5, 10 mL thin liquid, two 5 mL puree Varibar, and cracker were analyzed per subject (N = 1,755 swallows).Outcome measures included ordinal ratings of residue in the valleculae and pyriform sinuses. The correlation between clinical information and the present of pharyngeal residue structures was analyzed by Fisher's exact test for categorical variables and Wilcoxon's rank sum test for comparisons of continuous variables between groups. Result(s): Inter-and intra-rater reliability of the ordinal ratings were assessed using two-way random intraclass correlation coefficients (ICC(2,1)) on 20% of the data with good results (intra-rater: ICC = 0.92, 95% CI 0.70-0.97 and inter-rater: ICC = 0.92, 95% CI 0.81-0.97).The ratings of residue in the valleculae were significantly higher in the NTM group compared to the control group for one of the 3 mL bolus (p = 0.008), for 5 mL boluses (p = 0.009 and p = 0.004), 10 mL boluses (p = 0.0005 and p = 0.0006), puree (p = 0.006), cracker (p = 0.005).The ratings of residue in the pyriform sinuses were also significantly higher in the NTM group for 3 mL boluses (p = 0.0002 and p = 0.01), 5 mL boluses (p = 0.0003 and p = 0.002), 10 mL boluses (p = 0.001 and p = 0.001), puree trials (p<0.0001 and p<0.0001).Wilcoxon's rank sum test determined no age difference and Fisher's exact test determined no gender difference between the NTM and control groups. Conclusions (Including Clinical Relevance): Patients with NTM appear to have reduced bolus clearance than healthy individuals with no pulmonary disease, as represented by ratings of residue in the valleculae and pyriform sinuses.Future work is needed to elucidate the interaction between the respiratory-swallowing systems and airway protection and responsiveness to swallowing treatment for patients with NTM
EMBASE:631570672
ISSN: 1432-0460
CID: 4413812

Quantifying pharyngeal edema over time in head and neck cancer treated with chemoradiation [Meeting Abstract]

Molfenter, S M; Turcotte, M C; Herzberg, E G; Balou, M
Introduction: Edema is a frequent clinical observation after chemoradiation treatment (CRT) for oral/oropharyngeal cancer (O/OP Ca). Our aims were to reliably quantify edema from video fluoroscopy (VF) at 3 time points (baseline 1-month (mo) and 4-mo post CRT) and to explore the relationship between edema and (a) patient-reported outcomes (EAT-10) and (b) functional impairment on VF (Dynamic Imaging Grade of Swallowing Toxicity DIGEST).
Material(s) and Method(s): 15 patients (7 M; age 38-76) with O/OP Ca received radiotherapy (70 Gy 7 weeks) and 3 weekly doses of cisplatin. VF was completed pre-CRT 1-mo and 4-mo post-CRT. Edema was captured by measuring posterior pharyngeal wall (PPW) thickness and pharyngeal area (PA) at rest. EAT-10 surveys were completed on the day of VF. DIGEST scores were rated according to published protocols. Mixed model repeated measures ANOVAs were run for each edema measure (PPW PA) to test for the effect of TIME EAT-10 and DIGEST while controlling for age and sex.
Result(s): For PPW we found a main effect of TIME but not EAT-10 or DIGEST (Table 1). Post-hoc comparisons revealed a significant worsening from mean at baseline (4.1 mm) to 4-mo post CRT (6.0 mm) but not at 1-mo post CRT (5.4 mm). For PA we found a main effect of TIME and of DIGEST grade (Table 2). Mean PA was significantly smaller at 1-mo post CRT (527 mm2) compared with baseline (716 mm2) but not different from 4-mo post CRT (652 mm2). Mean PA was significantly greater for grade 2 (751 mm2) compared with grade 0 (442 mm2) contrary to the hypothesized direction.
Conclusion(s): The data confirm that post-CRT edema can be quantified on 2D lateral VF. Patient reported outcomes (EAT-10) were not independently predictive of edema. Surprisingly worse DIGEST grades were associated with increased pharyngeal area at rest perhaps reflecting impairment associated with pharyngeal atrophy not edema. Future work should monitor patients' edema and swallow function over a longer time period and at a greater frequency
EMBASE:631603502
ISSN: 1432-0460
CID: 4425862